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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003004
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:02:50 PM

Document Has Been Signed on 08/01/2024 02:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR/
DIRECTOR:		POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(279) 289-6907
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Persida PopTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 8/1/24/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator.

On 1/16/24, the department received a complaint regarding R1. While the complaint findings were delivered for those allegations, additional deficiencies were found in the course of the investigation.

LPA observed medications unattended during investigation visits on 5/23/24, caregiver dispensed medications to small cups on the kitchen counter and left the medications unattended to attend to a resident, and 6/11/24, a resident’s prescription nasal spray was on a kitchen counter. There are residents with dementia in care at the time. R1 had a LIC 602 in file that had identified it as having been for a prior facility with an examination date of 10/20/23 and a MD signature of 10/2023. The LIC 602 was not current for conditions for R1. R1 was admitted with pressure injuries that are noted to have begun in November 2023 that were not identified in the October LIC 602.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/01/2024 02:02 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 08/01/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LITTLE BROOK CARE HOME
FACILITY NUMBER: 345003004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/29/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care (h)The following requirements shall apply to medications. which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored
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Licensee will retrain staff who handled medications to strictly abide by the requirement that meds are not unsecure in the facility. submit proof of train.
The POC is due by 8/29/24
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medication.This requirement was not met based on observations on 2 occasions where medications were left unsecured,
for a short time, in an accessible area to residents. This posed a potential risk to residents
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Type B
08/29/2024
Section Cited
CCR87458(b)(2)

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Medical Assessment (b) The medical assessment shall include, but not be limited to: (2) Documentation of prior medical services and history and current medical status… This requirement was not met by a review of records finding R1 had medical condition not identified in the
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Licensee will sumbit a plan for review, assessments and updates of physician reports as needed for resident change of condition not previously identified.

POC due by 8/29/24.
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LIC 602. This posed a potential risk to R1. This requirement was not met based on record review that found R1’s LIC 602 to was not current to medical conditions at admission.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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